Healthcare Provider Details

I. General information

NPI: 1326314212
Provider Name (Legal Business Name): CENTER FOR DISCOVERY & ADOLESCENT CHANGE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/26/2012
Last Update Date: 03/26/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4281 KATELLA AVE STE 111
LOS ALAMITOS CA
90720-3588
US

IV. Provider business mailing address

4281 KATELLA AVE STE 111
LOS ALAMITOS CA
90720-3588
US

V. Phone/Fax

Practice location:
  • Phone: 714-828-1800
  • Fax: 714-828-1868
Mailing address:
  • Phone: 714-828-1800
  • Fax: 714-828-1869

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code323P00000X
TaxonomyPsychiatric Residential Treatment Facility
License Number980001602
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code323P00000X
TaxonomyPsychiatric Residential Treatment Facility
License Number980001593
License Number StateCA

VIII. Authorized Official

Name: MR. GERALD A CARMINIO
Title or Position: MANAGING DIRECTOR
Credential:
Phone: 714-828-1800